UPDATE F Ontario Drug Benefit Formulary/Comparative Drug Index No. 41 Effective 30 January, 2009 SUMMARY OF CHANGES TABLE OF CONTENTS Page New Single Source Drug(s) 2 New Multi-Source Drug(s) 3 Manufacturer Requested Discontinued Drug(s) 5 Delisted Drug(s) 6 Drug Benefit Price(s) 7 Off Formulary Interchangeable Product(s) 10 Discontinued Drug(s) (Removed From Payment & Listing) 11 Index 12 Page 1
New Single Source Drug(s) DIN PRODUCT GENERIC NAME MFR DBP 02278251 DuoTrav 0.5% & 0.004% Oph Sol- 2.5mL Pk TIMOLOL MALEATE & TRAVOPROST ALC 30.6000 Reason for Use Code Clinical Criteria 310 As second-line therapy for patients who do not have an adequate intraocular pressure lowering response to monotherapy with ophthalmic beta-blocking agents. LU Authorization Period: Indefinite. 393 For use as initial therapy in an urgent situation (e.g. patients with a high baseline intraocular pressure) where monotherapy is unlikely to be effective. LU Authorization Period: Indefinite. 02306778 Intelence 100mg Tab ETRAVIRINE JNO 5.4500 Note: For use in combination with an optimized regimen, for the treatment of HIV-1 infection in treatmentexperienced adult patients who have failed prior anti-retroviral therapies and have HIV-1 strains resistant to multiple antiretroviral agents, including protease inhibitors (PIs) and other non-nucleoside reverse transcriptase inhibitors (NNRTIs). Note: For the treatment of HIV/AIDS, the prescriber must be approved for the Facilitated Access mechanism. 02262347 Niaspan 500mg ER Tab NIACIN SEP 1.1975 02262355 Niaspan 750mg ER Tab NIACIN SEP 1.1975 02262339 Niaspan 1000mg ER Tab NIACIN SEP 1.1975 Note: For the treatment of dyslipidemia in patients who, after an adequate trial of crystalline niacin (defined as at least 1 month duration during which time appropriate dose titration, use of ASA and patient counseling have occurred), are unable to continue taking crystalline niacin because of intractable and intolerable side effects. 02261553 Telzir 50mg/mL Oral Susp FOSAMPRENAVIR CALCIUM GSK 0.5657 Note: For the treatment of HIV/AIDS, the prescriber must be approved for the Facilitated Access mechanism. Page 2
New Multi-Source Drug(s) DIN BRAND STRENGTH DOSAGE FORM MFR DBP 02244324 Apo-Cyclosporine Oral Solution (Interchangeable with Neoral) 100mg/mL O/L APX 3.7707 Reason for Use Code Clinical Criteria 177 For the treatment of psoriasis in patients who have failed, or are intolerant to, other systemic therapies, including methotrexate, Acitretin or PUVA LU Authorization Period: Indefinite. 178 For the treatment of rheumatoid arthritis in patients who have failed, or are intolerant to, other systemic therapies, including Disease- Modifying Antirheumatic Drugs (DMARDs). LU Authorization Period: Indefinite. 02291037 Apo-Diltiaz TZ 120mg SR Cap APX 0.4043 02291045 Apo-Diltiaz TZ 180mg SR Cap APX 0.5366 02291053 Apo-Diltiaz TZ 240mg SR Cap APX 0.7118 02291061 Apo-Diltiaz TZ 300mg SR Cap APX 0.8897 02291088 Apo-Diltiaz TZ 360mg SR Cap APX 1.0732 (Interchangeable with Tiazac) 02319225 Gen-Leflunomide 10mg Tab GEN 4.7950 02319233 Gen-Leflunomide 20mg Tab GEN 4.7950 (Interchangeable with Arava) Reason for Use Code Clinical Criteria 331 For the treatment of rheumatoid arthritis in patients who have failed,or are intolerant to, one or more of the listed Disease-Modifying Anti- Rheumatic Drugs (DMARDA). LU Authorization Period: Indefinite. Page 3
DIN BRAND STRENGTH DOSAGE FORM MFR DBP 02313405 Jamp-Citalopram 20mg Tab JPC 0.6250 02313413 Jamp-Citalopram 40mg Tab JPC 0.6250 (Interchangeable with Celexa) 02313685 Jamp-Ondansetron (Interchangeable with Zofran) 4mg Tab JPC 5.9884 Reason for Use Code Clinical Criteria 215 For the treatment of emesis in cancer patients receiving highly emetogenic chemotherapy. LU Authorization Period: 1 year. 216 For patients receiving intravenous chemotherapy or radiation therapy who have not experienced adequate control with other available anti-emetics. LU Authorization Period: 1 year. 217 For patients receiving intravenous chemotherapy or radiation therapy who experience intolerable side effects with other antiemetics. LU Authorization Period: 1 year. 218 For the treatment of emesis in patients receiving radiation therapy which consists of single fraction treatment to the abdominal cavity, hemi-body irradiation and total body irradiation. NOTE: The therapeutic value of Zofran more than 24 hours after the last dose of chemotherapy is unproven. LU Authorization Period: 1 year. Page 4
Manufacturer Requested Discontinued Drug(s) Please note that these discontinued products will remain on the formulary until the current stock is depleted. DIN BRAND STRENGTH DOSAGE FORM MFR 02248347 Combigan 0.2% & 0.5% Oph Sol-5mL Pk ALL 00344885 Cytoxan 50mg Tab BQU 00582247 Pondocillin 500mg Tab LEO 02291398 Sandoz Ramipril Tab 1.25mg SDZ 02291401 Sandoz Ramipril Tab 2.5mg SDZ 02291428 Sandoz Ramipril Tab 5mg SDZ 02291436 Sandoz Ramipril Tab 10mg SDZ 01913999 Symmetrel 10mg/mL O/L BQU Page 5
Delisted Drug(s) DIN BRAND STRENGTH DOSAGE FORM MFR 02162113 5-Benzagel 5% Gel NOV 00537594 Anthranol 0.1% Cr MEI 00537608 Anthranol 0.2% Cr MEI 00537616 Anthranol 0.4% Cr MEI 00566756 Anthraforte 1 1% Oint MEI 00566748 Anthraforte 2 2% Oint MEI 02275252 Ratio-Fosinopril 10mg Tab RPH 02275260 Ratio-Fosinopril 20mg Tab RPH Page 6
Drug Benefit Price(s) DIN BRAND STRENGTH DOSAGE FORM MFR DBP 02237618 Adalat XL 20mg ER Tab BAY 1.1889 02155907 Adalat XL 30mg ER Tab BAY 1.1889 02155990 Adalat XL 60mg ER Tab BAY 1.8747 00155357 Adrenalin 30mg/30mL Inj Sol-30mL Pk ERF 16.5000 00839175 Apo-Diclo 25mg Ent Tab APX 0.1563 02246860 Apo-Feno-Super 160mg Tab APX 0.5500 02242965 Avelox 400mg Tab BAY 5.7347 02060884 Betnesol 5mg/100mL Enema-100mL Pk SQI 9.0557 01984845 Bonefos 400mg Cap BAY 1.8025 00476366 Choledyl 20mg/mL O/L ERF 0.0360 02247916 Cipro XL 500mg ER Tab BAY 2.9882 02251787 Cipro XL 1000mg ER Tab BAY 2.9882 00579335 Cortifoam 10% Rect Aero-15g Pk SQI 79.3700 02240113 Cosopt 2% & 0.5% Oph Sol MFC 5.6820 02182815 Cozaar 25mg Tab MFC 1.2500 02182874 Cozaar 50mg Tab MFC 1.2500 02182882 Cozaar 100mg Tab MFC 1.2500 01968440 Cyclen 0.25mg & 0.035mg Tab-21 Pk JNO 15.2350 01992872 Cyclen 0.25mg & 0.035mg Tab-28 Pk JNO 15.2350 01937383 Duragesic 25 25mcg/hr Trans Patch JNO 10.4520 01937391 Duragesic 50 50mcg/hr Trans Patch JNO 19.6680 01937405 Duragesic 75 75mcg/hr Trans Patch JNO 27.6620 01937413 Duragesic 100 100mcg/hr Trans Patch JNO 34.4320 01947958 Duvoid 10mg Tab SQI 0.2654 01947931 Duvoid 25mg Tab SQI 0.4300 01947923 Duvoid 50mg Tab SQI 0.5664 00851744 Elocom 0.1% Cr SCH 0.6654 02247521 Ezetrol 10mg Tab MFS 1.7248 02086026 Florinef 0.1mg Tab SQI 0.2349 02246226 Fludara 10mg Tab BAY 38.9080 02201011 Fosamax 10mg Tab MFC 1.9946 02245329 Fosamax 70mg Tab MFC 10.0575 02190885 Glucobay 50mg Tab BAY 0.2588 02190893 Glucobay 100mg Tab BAY 0.3584 02230047 Hyzaar 50mg/12.5mg Tab MFC 1.2500 02241007 Hyzaar DS 100mg/25mg Tab MFC 1.2500 02240693 Intron A 15mu/mL 18mu MD Pen Kit SCH 210.0600 02240694 Intron A 25mu/mL 30mu MD Pen Kit SCH 350.1000 02240695 Intron A 50mu/mL 60mu MD Pen Kit SCH 700.1900 02022117 Leustatin 1mg/mL Inj JNO 55.1720 00074454 Locacorten-Vioform 0.02% & 1% Ot Sol SQI 1.4080 00297143 Loestrin 1.5/30 0.03mg & 1.5mg Tab-21 Pk SQI 12.4000 00353027 Loestrin 1.5/30 0.03mg & 1.5mg Tab-28 Pk SQI 12.4000 02042487 Marvelon 21 0.15mg & 0.03mg Tab-21 Pk ORG 13.1700 02042479 Marvelon 28 0.15mg & 0.03mg Tab-28 Pk ORG 13.1700 Page 7
DIN BRAND STRENGTH DOSAGE FORM MFR DBP 00795860 Mevacor 20mg Tab MFC 1.9675 00795852 Mevacor 40mg Tab MFC 3.5939 00037605 Micronor 0.35mg Tab-28 Pk JNO 15.2350 00315966 Minestrin 1/20 0.02mg & 1mg Tab-21 Pk SQI 12.4000 00343838 Minestrin 1/20 0.02mg & 1mg Tab-28 Pk SQI 12.4000 02243005 Mirena 52mg Insert BAY 322.8300 00024430 Navane 2mg Cap ERF 0.3100 00024449 Navane 5mg Cap ERF 0.3450 01926772 Neuleptil 10mg Cap ERF 0.3000 01926454 Nitrol 2% Oint SQI 0.6082 02289091 Novo-Fenofibrate-S 160mg Tab NOP 0.5500 00317047 Ortho 0.5/35 0.035mg & 0.5mg Tab-21 Pk JNO 15.2350 00340731 Ortho 0.5/35 0.035mg & 0.5mg Tab-28 Pk JNO 15.2350 00372846 Ortho 1/35 0.035mg & 1mg Tab-21 Pk JNO 15.2350 00372838 Ortho 1/35 0.035mg & 1mg Tab-28 Pk JNO 15.2350 00602957 Ortho 7/7/7 3 Phase Tab-21 Pk JNO 15.2350 00602965 Ortho 7/7/7 3 Phase Tab-28 Pk JNO 15.2350 02042533 Ortho-Cept 0.15mg & 0.03mg Tab-28 Pk JNO 15.2350 00789445 Pancrease MT4 4000 & 12000 & Ent Microsph Cap JNO 0.4142 12000 USP Units 01927744 Parsitan 50mg Tab ERF 0.2035 02153564 Pentasa 1g Sup FEI 1.6000 00710121 Pepcid 20mg Tab MFC 1.0632 00710113 Pepcid 40mg Tab MFC 1.9336 02241674 Plan B 0.75mg Tab-2 Tabs Pk PAL 17.2000 00893749 Pravachol 10mg Tab BQU 0.7567 00893757 Pravachol 20mg Tab BQU 0.8925 02222051 Pravachol 40mg Tab BQU 1.0750 02284057 Prezista 300mg Tab JNO 7.1690 00839388 Prinivil 5mg Tab MFC 0.5713 00839396 Prinivil 10mg Tab MFC 0.6864 00839418 Prinivil 20mg Tab MFC 0.8253 02108194 Prinzide 10mg & 12.5mg Tab MFC 0.7074 00884413 Prinzide 20mg & 12.5mg Tab MFC 0.8500 00638692 Procan SR 250mg LA Tab ERF 0.3000 00638676 Procan SR 500mg LA Tab ERF 0.5000 00638684 Procan SR 750mg LA Tab ERF 0.8050 02089602 Propaderm 0.025% Cr SQI 0.4371 02010909 Proscar 5mg Tab MFC 1.8530 02266717 Reminyl ER 8mg ER Cap JNO 4.8690 02266725 Reminyl ER 16mg ER Cap JNO 4.8690 02266733 Reminyl ER 24mg ER Cap JNO 4.8690 01916823 Ridaura 3mg Cap SQI 2.0047 02236950 Risperdal 1mg/mL O/L JNO 1.3720 02240551 Risperdal 0.25mg Tab JNO 0.5257 02240552 Risperdal 0.5mg Tab JNO 0.8806 02025280 Risperdal 1mg Tab JNO 1.2165 02025299 Risperdal 2mg Tab JNO 2.4285 02025302 Risperdal 3mg Tab JNO 3.6430 02025310 Risperdal 4mg Tab JNO 4.8575 Page 8
DIN BRAND STRENGTH DOSAGE FORM MFR DBP 02255707 Risperdal Consta 25mg Pd for Inj-Vial Pk JNO 152.2900 02255723 Risperdal Consta 37.5mg Pd for Inj-Vial Pk JNO 228.4200 02255758 Risperdal Consta 50mg Pd for Inj-Vial Pk JNO 304.5600 02247704 Risperdal M-Tab 0.5mg Orally Disintegrating Tab JNO 0.7250 02247705 Risperdal M-Tab 1mg Orally Disintegrating Tab JNO 1.0025 02247706 Risperdal M-Tab 2mg Orally Disintegrating Tab JNO 2.0000 02268086 Risperdal M-Tab 3mg Orally Disintegrating Tab JNO 3.0000 02268094 Risperdal M-Tab 4mg Orally Disintegrating Tab JNO 4.0000 00329320 Sandomigran 0.5mg Tab SQI 0.3688 00511552 Sandomigran DS 1mg Tab SQI 0.6124 02243602 Singulair 4mg Chew Tab MFC 1.4410 02241093 Temodal 5mg Cap SCH 7.3440 02241094 Temodal 20mg Cap SCH 29.3756 02241095 Temodal 100mg Cap SCH 146.8780 02241096 Temodal 250mg Cap SCH 367.1847 00894729 Terazol 7 0.4% Cr JNO 0.4464 00023949 Thyroid 30mg Tab ERF 0.0520 00023957 Thyroid 60mg Tab ERF 0.0640 00023965 Thyroid 125mg Tab ERF 0.0920 00451207 Timoptic 0.5% Oph Sol MFC 3.4700 02171880 Timoptic-XE 0.25% Oph Gellan Sol MFC 3.7040 02171899 Timoptic-XE 0.5% Oph Gellan Sol MFC 4.4320 02230893 Topamax 25mg Tab JNO 1.2512 02230894 Topamax 100mg Tab JNO 2.3715 02230896 Topamax 200mg Tab JNO 3.5415 02239907 Topamax Sprinkle 15mg Sprinkle Cap JNO 1.1420 02239908 Topamax Sprinkle 25mg Sprinkle Cap JNO 1.1990 02106272 Trandate 100mg Tab SQI 0.2548 02106280 Trandate 200mg Tab SQI 0.4505 02028700 Tri-Cyclen 3 Phase Tab-21 Pk JNO 15.2350 02029421 Tri-Cyclen 3 Phase Tab-28 Pk JNO 15.2350 02258560 Tri-Cyclen Lo 3 Phase Tab-21 Pk JNO 12.0000 02258587 Tri-Cyclen Lo 3 Phase Tab-28 Pk JNO 12.0000 00707600 Triquilar 21 3 Phase Tab-21 Pk BAY 14.1500 00707503 Triquilar 28 3 Phase Tab-28 Pk BAY 14.1500 02216205 Trusopt 2% Oph Sol MFC 3.7500 00556734 Vermox 100mg Tab JNO 3.5050 00884324 Zocor 5mg Tab MFC 1.0225 00884332 Zocor 10mg Tab MFC 2.0232 00884340 Zocor 20mg Tab MFC 2.5004 00884359 Zocor 40mg Tab MFC 2.5004 02240332 Zocor 80mg Tab MFC 2.5004 Page 9
Off Formulary Interchangeable Product(s) DIN BRAND STRENGTH DOSAGE FORM MFR UNIT COST 02253933 PMS-Ciprofloxacin (Interchangeable with Ciloxan) 0.3% Oph Sol-5mL Pk PMS 5.6400 02319977 PMS-Oxycodone 5mg Tab PMS 0.1776 02319985 PMS-Oxycodone 10mg Tab PMS 0.2760 02319993 PMS-Oxycodone (Interchangeable with Oxy.IR) 20mg Tab PMS 0.4358 Page 10
Discontinued Drug(s) (Removed From Payment & Listing) DIN BRAND STRENGTH DOSAGE FORM MFR 09853570 Nutrisure Pudding 113g Pk ABB 00580201 Percocet 5mg & 325mg Tab BQU 00580236 Percodan 5mg & 325mg Tab BQU Page 11